CONTENTS
0. Moderators Note: This is the last SIGNpost in the current series
1. Abstract: Blood exposure accidents: knowledge and practices of hospital
health workers in Mali
2. Abstract: Sharps injuries amongst healthcare workers: review of
incidence, transmissions and costs
3. Abstract: Factors Associated with Needlestick Injuries in Health Care
Occupations: A Systematic Review
4. Abstract: Occupational exposure to blood among hospital workers in
montenegro
5. Abstract: Facilitating the safe use of insulin pens in hospitals
through a mentored quality-improvement program
6. Abstract: Effectiveness of the behavior change intervention to improve
harm reduction self-efficacy among people who inject drugs in Thailand
7. Abstract: Assessment of health-care waste management in a humanitarian
crisis: A case study of the Gaza Strip
8. Abstract: HCV epidemiology in high-risk groups and the risk of
reinfection
9. Abstract: Oral and injectable contraceptive use and HIV acquisition
risk among women in four African countries: a secondary analysis of
data from a microbicide trial
10. Abstract: Delivery of long-acting injectable antivirals: best
approaches and recent advances
11. Abstract: Measles 50 Years After Use of Measles Vaccine
12. News
– Pakistan: Another Congo patient dies in Peshawar

Normally, items received by Tuesday will be posted in the Wednesday
edition.

Subscribe or unsubscribe by email: signmoderator@googlegroups.com

Visit the WHO injection safety website and the SIGN Alliance Secretariat
at: http://www.who.int/injection_safety/en/

Visit the SIGNpostOnline archives at: http://signpostonline.info

Like SIGNpost on Facebook at: https://www.facebook.com/SIGN.Moderator
and get updates on your device!
__________________________________________________________________
________________________________*_________________________________

0. Moderators Note: This is the last SIGNpost in the current series
__________________________________________________________________
The SIGN Internet Forum was established at the initiative of the World
Health Organization in November 1999.

We are sorry to announce the suspension of the SIGNpost listserv.

Due to serious financial constraints WHO has suspended SIGNpost.

This is the last SIGNpost in the current series.

It has been a pleasure to assist SIGNpost readers and their colleagues and
organizations to stay up to date on injection safety: WHO and partner
organization announcements, reports and tools, the latest abstracts of the
injection safety and related infection control literature, health care
waste management reports and developments, and related global news
reports, and where useful, press releases.

We hope you have found SIGNpost useful in your work.

Our colleagues Arshad Altaf and Selma Khamassi will endeavour to post
monthly updates beginning in late October. I will help them to master the
technology, tools and methods used to produce and distribute SIGNpost.

The SIGNpost archive website at http://signpostonline.info/ will be up and
online until sometime in 2017.

There is much remaining to do to achieve universal injection safety.

regards and very best wishes,
allan
__________________________________________________________________
________________________________*_________________________________

This is a prospective study conducted in December 2012 among 128 at the
Nianankoro Fomba Hospital in Segou in order to assess their knowledge and
practices on Blood Exposure Accidents (BEA).

The average age of caregivers was 35.4 ± 9 years (range: 22-59 years). The
nurses were predominant with 37.5%. The definition of BEA was mastered by
43.8%. The main transmissible infectious agents (HIV, HBV and HCV) were
ignored by 76.6%.

Questioning revealed that during the treatment, 78.9% wore gloves and
36.0% recapped needles after use.

The concept of washing and disinfection after BEA was known by 68.8%. The
disinfectant applied was correct for 21.9% of the cases, the time of
application for 69.5%.

Consulting a referring physician after BEA was mandatory for 32% of them.
The time limit of 48 hours delay for the declaration of BEA was
experienced by 51.3%.

Among staff interviewed 82 caregivers (64.1%) experienced at least one
BEA. Students and nursing students were most at risk. Needle pricks were
the most frequent (73.2%). BEA is a major problem in the Segou Nianankoro
Fomba Hospital.

Compliance with standard precautions is not of common practice. Post-
exposure care is not widely known. The experienced cases show poor
management of BEA in the structure.

1Department of Nursing Sciences, Faculty of Medicine and Public Health,
University of Antwerp, Antwerp, Belgium.

BACKGROUND: Sharps injuries and the related risk of infections such as
hepatitis B virus (HBV), hepatitis C virus (HCV) and human
immunodeficiency virus (HIV) represent one of the major occupational
health risks for healthcare workers (HCWs).

LITERATURE REVIEW: An overview of available data on the incidence of
sharps injuries and the related HBV, HCV and HIV infections and ensuing
costs is provided.

RESULTS: Literature reported incidence rates of sharps injuries ranging
from 1.4 to 9.5 per 100 HCWs, resulting in a weighted mean of 3.7/100 HCWs
per year. Sharps injuries were associated with infective disease
transmissions from patients to HCWs resulting in 0.42 HBV infections,
0.05-1.30 HCV infections and 0.04-0.32 HIV infections per 100 sharps
injuries per year. The related societal costs had a mean of €272,
amounting to a mean of €1,966 if the source patient was HIV positive with
HBV and HCV co-infections.

INTRODUCTION: Needlestick and sharps injuries (NSIs), are among the main
job-related injuries that health care workers experience. In fact,
contraction of hepatitis B or hepatitis C from work-related NSIs is one of
the most common occupational hazards among health care workers.

AIM: The aim of this study was to determine the factors associated with
NSIs in health care occupation.

MATERIALS AND METHODS: In this study, a systematic and purposive review
with emphasis on the research question was run to retrieve, evaluate and
consolidate the required information. The following four key words were
used to search for the relevant articles published from January 1998 to
May 2015: NSI health care workers, risk factor and factors associated, in
Science direct, EBSCO Host, PubMed, ProQuest, SID and Cochrane Library.
Several steps of evaluation were taken to select and analyse the full
texts of relevant articles. According to the inclusion criteria, we
finally selected 11 articles from the 18642 retrieved articles.

RESULTS: The data of the analysed articles indicated that the highest
incidence of NSIs was seen in nurses and that the associated factors were
age, level of education, number of shifts per month and history of related
training. The highest rate of NSIs was related to instrument preparation
followed by injection and recapping of used needles. Findings show that
health care workers suffer a high rate of needlestick injuries.

CONCLUSION: It was seen that device, location, or action cannot be
separately considered as responsible for all types of the NSIs. Rather,
each of them has a contribution to the NSIs. Nevertheless, factors with
higher frequency should be given a higher priority.

This cross-sectional study was performed in nine Montenegrin hospitals to
estimate the burden of occupational exposure to blood among hospital
workers in Montenegro in 2010 using a modified Croatian self-reporting
questionnaire on exposure to blood-borne infections.

Of the 1043 respondents, 517 (49.6 %) reported exposure to blood.
Variations between the hospitals were not significant, except for the
hospital in Kotor, which stands out with the high percentage of exposed
hospital workers (p<0.05). More than 77 % of exposures were not reported
through standard hospital protocols at the time of the incident. The most
exposed group to blood were nurses (357 of 517; 69.1 %), but the
percentage of exposed nurses within the group did not stand out compared
to other occupations and was close to that reported by physicians (50.57 %
vs. 57.49 %, respectively).

The number of hospital workers with appropriate HBV vaccination was
surprisingly low (35.7 %) and significantly below the recommended best
practice (at least two consecutive doses of HBV vaccine documented for 100
% of employees) (p<0.001).

Even with its limitations, our study fills a gap in knowledge about the
actual number of sharps incidents and other occupational exposure to blood
among hospital workers in Montenegro as well as about the issue of
underreporting, which is very common.

It also confirms the urgent need for active implementation of special,
comprehensive measures to prevent needle-stick and other sharps injuries.

PURPOSE: Results of the MENTORED QUALITY IMPROVEMENT IMPACT PROGRAM?
(MQIIP) on Ensuring Insulin Pen Safety in Hospitals, which was part of an
ASHP educational initiative aimed at ensuring the safe use of insulin pens
in hospitals, are described.

METHODS: During this ASHP initiative, which also included continuing-
education activities and Web-based resources, distance mentoring by
pharmacists with expertise in the safe use of insulin pens was provided to
interprofessional teams at 14 hospitals between September 2014 and May
2015. The results of baseline assessments of nursing staff knowledge of
insulin pen use, insulin pen storage and labeling audits, and insulin pen
injection observations conducted in September and October 2014 were the
basis for insulin pen quality-improvement plans. Postintervention data
were collected in April and May 2015.

RESULTS: Compared with the baseline period, significant improvements in
nurses’ knowledge of insulin pen use, insulin pen labeling and storage,
and insulin pen administration were observed in the postintervention
period despite the relatively short time frame for implementation of
quality-improvement plans. Program participants are committed to
sustaining and building on improvements achieved during the program. The
outcome measures described in this report could be adapted by other health
systems to identify opportunities to improve the safety of insulin pen
use.

6. Abstract: Effectiveness of the behavior change intervention to improve
harm reduction self-efficacy among people who inject drugs in Thailand
__________________________________________________________________

1College of Public Health Sciences, Chulalongkorn University.
2College of Public Health Sciences, Chulalongkorn University; Drug
Dependence Research Center WHO Collaborating Centre for Research and
Training in Drug Dependence, Bangkok, Thailand.

BACKGROUND: People who inject drugs (PWID) in Thailand reported unsafe
injection practices resulting in injection-related health consequences.
Harm reduction self-efficacy plays an important role and could be improved
to reduce harm associated with injecting drugs. Evidence-based
interventions targeting PWID are needed. This study sought to evaluate the
effectiveness of the behavior change intervention within the PWID
population.

METHODS: The behavior change intervention, Triple-S, was designed to
improve harm reduction self-efficacy among PWID. This quasi-experimental
study was a pre- and post-comparison with a control group design.
Participants were PWID, aged 18-45 years, and located in Bangkok. Changes
in harm reduction self-efficacy of the intervention group were compared
with the control group using paired and independent t-test.

RESULTS: Most of PWID were male (84%), had a secondary school and lower
education (71%), were single, and had a mean age of 41 years. They had
been injecting drugs for an average of 20 years, and the median of drug
injections per week was ten times in the past month. Pre- and post-
intervention effects were measured and results showed that the
intervention group reported improvement in harm reduction self-efficacy in
negative emotional conditions (P=0.048).

CONCLUSION: Our findings suggest that Triple-S intervention can
significantly improve harm reduction self-efficacy in negative emotional
conditions. The results may suggest the importance of behavior change
intervention, especially when integrated with services provided by drop-in
centers. The intervention can be further developed to cover other harm
reduction behaviors and improve harm reduction self-efficacy.

Health-care waste management requires technical, financial and human
resources, and it is a challenge for low- and middle income countries,
while it is often neglected in protracted crisis or emergency situations.
Indeed, when health, safety, security or wellbeing of a community is
threatened, solid waste management usually receives limited attention.

Using the Gaza Strip as the case study region, this manuscript reports on
health-care waste management within the context of a humanitarian crisis.
The study employed a range of methods including content analyses of
policies and legislation, audits of waste arisings, field visits,
stakeholder interviews and evaluation of treatment systems.

The study estimated a production from clinics and hospitals of 683kg/day
of hazardous waste in the Gaza Strip, while the total health-care waste
production was 3357 kg/day. A number of challenges was identified
including lack of clear definitions and regulations, limited accurate data
on which to base decisions and strategies and poor coordination amongst
key stakeholders. Hazardous and non-hazardous waste was partially
segregated and treatment facilities hardly used, and 75% of the hazardous
waste was left untreated.

Recommendations for mitigating these challenges posed to patients, staff
and the community in general are suggested. The outputs are particularly
useful to support decision makers, and re- organize the system according
to reliable data and sound assumptions. The methodology can be replicated
in other humanitarian settings, also to other waste flows, and other
sectors of environmental sanitation.

Injecting risk behaviours among people who inject drugs (PWID) and high-
risk sexual practices among men who have sex with men (MSM) are important
routes of hepatitis C virus (HCV) transmission. Current direct-acting
antiviral treatment offers unique opportunities for reductions in HCV-
related liver disease burden and epidemic control in high-risk groups, but
these prospects could be counteracted by HCV reinfection due to on-going
risk behaviours after successful treatment.

Based on existing data from small and heterogeneous studies of interferon-
based treatment, the incidence of reinfection after sustained virological
response range from 2-6/100 person years among PWID to 10-15/100 person
years among human immunodeficiency virus-infected MSM. These differences
mainly reflect heterogeneity in study populations with regards to risk
behaviours, but also reflect variations in study designs and applied
virological methods.

Increasing levels of reinfection are to be expected as we enter the
interferon-free treatment era. Individual- and population-level efforts to
address and prevent reinfection should therefore be undertaken when
providing HCV care for people with on-going risk behaviour.

9. Abstract: Oral and injectable contraceptive use and HIV acquisition
risk among women in four African countries: a secondary analysis of
data from a microbicide trial
__________________________________________________________________

Contraception. 2016 Jan;93(1):25-31. Free Full Text
Oral and injectable contraceptive use and HIV acquisition risk among women
in four African countries: a secondary analysis of data from a microbicide
trial.

1Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA. Electronic address: jbalkus@fhcrc.org.
2Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA.
3Department of Obstetrics, Gynecology and Reproductive Sciences and the
Magee-Women’s Research Institute, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA.
4FHI360, Durham, NC, USA.
5HIV Prevention Research Unit, South Africa Medical Research Council,
Durban, South Africa.
6University of Zimbabwe – University of California San Francisco Research
Program, Harare, Zimbabwe.
7College of Medicine, University of Malawi, Blantyre, Malawi.
8Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
9University of North Carolina Project, Kamuzu Central Hospital, Lilongwe,
Malawi.
10National Institutes of Health, Bethesda, MD, USA.
11Centre for the AIDS Program of Research in South Africa, Doris Duke
Medical Research Institute, Nelson R. Mandela School of Medicine,
University of KwaZulu-Natal, Congella, South Africa; Department of
Epidemiology, Mailman School of Public Health, Columbia University, New
York, NY, USA.

OBJECTIVE: To assess the effect of oral and injectable contraceptive use
compared to nonhormonal contraceptive use on HIV acquisition among
Southern African women enrolled in a microbicide trial.

STUDY DESIGN: This is a prospective cohort study using data from women
enrolled in HIV Prevention Trials Network protocol 035. At each quarterly
visit, participants were interviewed about self-reported contraceptive use
and sexual behaviors and underwent HIV testing. Cox proportional hazards
regression was used to assess the effect of injectable and oral hormonal
contraceptive use on HIV acquisition.

CONCLUSION: In this secondary analysis of randomized trial data, a
marginal, but nonstatistically significant, increase in HIV risk among
women using injectable hormonal contraceptives was observed. No increased
HIV risk was observed among women using oral contraceptives. Our findings
support the World Health Organization’s recommendation that women at high
risk for acquiring HIV, including those using progestogen-only injectable
contraception, should be strongly advised to always use condoms and other
HIV prevention measures.

IMPLICATIONS: Among Southern African women participating in an HIV
prevention trial, women using injectable hormonal contraceptives had a
modest increased risk of HIV acquisition; however, this association was
not statistically significant. Continued research on the relationship
between widely used hormonal contraceptive methods and HIV acquisition is
essential.

PURPOSE OF REVIEW: Treatment of chronic disease in a manner that promotes
compliance and patient adherence has necessitated the consideration for
drug delivery approaches that reduce the burden of regimens requiring
daily treatment. Long-acting injectable (LAI) products have been developed
in many disease areas and are now being exploited for the treatment of
infectious disease, most notably HIV.

RECENT FINDINGS: Research published over the past 3 years has shown that
LAI nanosuspensions of nonnucleoside reverse transcriptase inhibitors and
integrase inhibitors provide extended exposure to the active drug over a
period of days to weeks. Some of these candidates are currently in
clinical study and are highly anticipated medications for the prevention
of HIV.

SUMMARY: LAIs represent a growing need in the treatment of chronic
infections. To date, the approach has been most successfully applied in
the treatment of HIV, but could certainly be expanded into other diseases
like tuberculosis. Most importantly, LAIs can provide a means to help
prevent the emergence of resistance which may be attributed to lack of
compliance to regimens requiring daily, oral administration.
__________________________________________________________________
________________________________*_________________________________

11. Abstract: Measles 50 Years After Use of Measles Vaccine
__________________________________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/26610423

Infect Dis Clin North Am. 2015 Dec;29(4):725-43.
Measles 50 Years After Use of Measles Vaccine.

In response to severe measles, the first measles vaccine was licensed in
the United States in 1963. Widespread use of measles vaccines for more
than 50 years has significantly reduced global measles morbidity and
mortality.

However, measles virus continues to circulate, causing infection, illness,
and an estimated 400 deaths worldwide each day. Measles is preventable by
vaccine, and humans are the only reservoir.

Clinicians should promote and provide on-time vaccination for all patients
and keep measles in their differential diagnosis of febrile rash illness
for rapid case detection, confirmation of measles infection, isolation,
treatment, and appropriate public health response.

Dr Wasim Khawaja, a public health specialist at Pakistan Institute of
Medical Sciences (PIMS), said reducing the risk of tick-to-human
transmission people should wear protective clothing like long sleeves or
long trousers and wear light coloured clothing to allow easy detection of
ticks on the clothes.

He said people should use approved chemicals intended to kill ticks on
clothing, use approved repellent on the skin and clothing, regularly
examine clothing and skin for ticks, if found, remove them and avoid
areas where ticks are abundant and seasons when they are most active.

Dr Khawaja said in order to reducing the risk of animal-to-human
transmission people should wear gloves and other protective clothing while
handling animals or their tissues in endemic areas, notably during
slaughtering, butchering and culling procedures in slaughterhouses or at
home.

He added to reduce the risk of human-to-human transmission in the
community, people should avoid close physical contact with

CCHF-infected people, wear gloves and protective equipment when taking
care of ill people and wash hands regularly after caring for or visiting
ill people.

Medical practitioner at Federal Government Poly Clinic (FGPC)

Dr Sharif Astori said the virus is primarily transmitted to people from
ticks and livestock animals.

He added human-to-human transmission can occur resulting from close
contact with the blood, secretions, organs or other bodily fluids of
infected persons.

He said CCHF is a widespread disease caused by a tick-borne virus. The
hosts of the CCHF virus included a wide range of wild and domestic animals
such as cattle, sheep and goats.

He said animals become infected by the bite of infected ticks and the
virus remains in their bloodstream for about one week after infection,
allowing the tick-animal-tick cycle to continue when another tick bites.

The CCHF virus is transmitted to people either by tick bites or through
contact with infected animal blood or tissues during and immediately after
slaughter, he added.

He said majority of cases have occurred in people involved in the
livestock industry, such as agricultural workers, slaughterhouse workers
and veterinarians.

He said human-to-human transmission can occur resulting from close contact
with the blood, secretions, organs or other bodily fluids of infected
persons.

**** Hospital-acquired infections can also occur due to improper
sterilization of medical equipment, reuse of needles and contamination of
medical supplies, he added.

He said following infection by a tick bite, the incubation period is
usually one to three days, with a maximum of nine days.

The incubation period following contact with infected blood or tissues is
usually five to six days, with symptoms included fever, muscle ache,
dizziness, neck pain and stiffness, backache, headache, sore eyes and
photophobia (sensitivity to light).

He said there may be nausea, vomiting, diarrhoea, abdominal pain and sore
throat early on, followed by sharp mood swings and confusion. After two to
four days, the agitation may be replaced by sleepiness, depression and
lassitude, and the abdominal pain may localize to the upper right
quadrant, with detectable hepatomegaly (liver enlargement).

He said other clinical signs included fast heart rate), enlarged lymph
nodes, and a rash caused by bleeding into the skin on internal mucosal
surfaces, such as in the mouth and throat, and on the skin.

Dr Astori said there is usually evidence of hepatitis, and severely ill
patients may experience rapid kidney deterioration, sudden liver failure
or pulmonary failure after the fifth day of illness.

The mortality rate from CCHF is approximately 30%, with death occurring in
the second week of illness. In patients who recover, improvement generally
begins on the ninth or tenth day after the onset of illness.
__________________________________________________________________
________________________________*_________________________________

New WHO Injection Safety Guidelines

WHO is urging countries to transition, by 2020, to the exclusive use of
the new “smart” syringes, except in a few circumstances in which a syringe
that blocks after a single use would interfere with the procedure.

The new guideline is:

WHO Guideline on the use of Safety-Engineered Syringes for Intramuscular,
Intradermal and Subcutaneous Injections in Health Care

It is available for free download or viewing at this link:
www.who.int/injection_safety/global-campaign/injection-safety_guidline.pdf

* Download the WHO Best Practices for Injections and Related Procedures
Toolkit March 2010 [pdf 2.47Mb]:
http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf

Use the Toolbox at: http://www.who.int/injection_safety/toolbox/en/

Get SIGN files on the web at: http://signpostonline.info/signfiles-2 get
SIGNpost archives at: http://signpostonline.info/archives-by-year

Like on Facebook: http://facebook.com/SIGN.Moderator

The SIGN Secretariat, the Department of Health Systems Policies and
Workforce, WHO, Avenue Appia 20, CH-1211 Geneva 27, Switzerland.
Facsimile: +41 22 791 4836 E- mail: sign@who.int
__________________________________________________________________
________________________________*_________________________________
All members of the SIGN Forum are invited to submit messages, comment on
any posting, or to use the forum to request technical information in
relation to injection safety.

The comments made in this forum are the sole responsibility of the writers
and does not in any way mean that they are endorsed by any of the
organizations and agencies to which the authors may belong.

Use of trade names and commercial sources is for identification only and
does not imply endorsement.

The SIGN Forum welcomes new subscribers who are involved in injection
safety.

* Subscribe or unsubscribe by email: signmoderator@googlegroups.com

The SIGNpost Website is http://SIGNpostOnline.info

The SIGNpost website provides an archive of all SIGNposts, meeting
reports, field reports, documents, images such as photographs, posters,
signs and symbols, and video.
__________________________________________________________________
________________________________*_________________________________

The SIGN Internet Forum was established at the initiative of the World
Health Organization’s Department of Essential Health Technologies.

The SIGN Secretariat home is the Service Delivery and Safety (SDS) Health
Systems and Innovation (HIS) at WHO HQ, Geneva Switzerland.

The SIGN Forum is moderated by Allan Bass and is hosted on GoogleGroups